Fillable STATEMENT OF INTENT TO EMPLOY A MINOR AND

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STATEMENT OF INTENT TO EMPLOY A MINOR AND

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Copy–District or County Superintendent; Employer; Parent or Legal Guardian (Over)
STATE OF CALIFORNIA DEPARTMENT OF EDUCATION
STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–
CERTIFICATE OF AGE
CDE B1-1 (Rev. 07-10)
A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–CERTIFICATE OF AGE” form
(CDE B1-1) shall be completed in accordance with California Education Code 49162 and 49163 as notification of intent to employ a
minor. This form is also a Certificate of Age pursuant to California Education Code 49114.
(Print Information)
Minor’s Information
Minor’s Name (First and Last)
Home Phone
Birth Date
Social Security Number
Grade
Age
Home Address
City
Zip Code
School Information
School Name
School Phone
School Address
City
Zip Code
To be filled in and signed by employer. (Please review the General Summary of Minors’ Work Regulations on reverse.)
Business Name or Agency of Placement
Business Phone
Supervisor’s Name
Business Address
City
Zip Code
Describe nature of work to be performed:
In compliance with California labor laws, this employee is covered by worker’s compensation insurance. This business does not
discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age,
physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.
Employer’s Name (Print First and Last)
Employer’s Signature
Date
To be filled in and signed by parent or legal guardian
This minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of my
knowledge and belief, the information herein is correct and true. I request that a work permit be issued.
Parent or Legal Guardian’s Name (Print First and Last)
Parent or Legal Guardian’s Signature
Date
For authorized work permit issuer use ONLY
Maximum number of hours of employment when school is in session:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
Check Permit Type:
*
Full-time
**
Workability
Restricted
General
***
Work Experience
Education, Vocational
Education, or Personal
Attendant
Proof of Minor’s Age (Evidence Type)
Verifying Authority’s Name and Title (Print)
Verifying Authority’s Signature
*
EC 49130 |
**
Permit Type defined by local school |
***
Special Education Grant
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STATE OF CALIFORNIA DEPARTMENT OF EDUCATION
STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT—
CERTIFICATE OF AGE
CDE B1-1 (Rev. 07-10)
General Summary of Minors’ Work Regulations
FLSA-Federal Labor Standards Act, CDE-California Department of Education, EC-California Education Code, LC-California Labor
Code, CFR-California Federal Regulations
If federal laws, state laws, and school district policies
conflict, the more restrictive law (the one most
protective of the minor) prevails. (FLSA)
Employers of minors required to attend school must
complete a “Statement of Intent to Employ a Minor and
Request for Work Permit” (CDE B1-1) for the school
attendance for each such minor. (EC 49162)
Employers must retain a “Permit to Employ and Work”
(CDE B1-4) for each such minor. (EC 49161)
Work permits (CDE B1-4) must be retained for three years
and be available for inspection by sanctioned authorities at
all times. (EC 49164)
A work permit (CDE B1-4) must be revoked whenever the
issuing authority determines the employment is illegal or is
impairing the health or education of the minor. (EC 49164)
A day of rest from work is required in every seven days,
and shall not exceed six days in seven.
(LC 551, 552)
Minors under the age of 18 may not work in environments
declared hazardous or dangerous for young workers, examples
listed below: (LC 1294.1 and 1294.5, 29 CFR 570 Subpart E)
1. Explosive exposure
2. Motor vehicle driving/outside helper
3. Roofing
4. Logging and sawmilling
5. Power-driven woodworking machines
6. Radiation exposure
7. Power-driven hoists/forklifts
8. Power-driven metal forming, punching, and shearing
machines
9. Power saws and shears
10. Power-driving meat slicing/processing machines
HOURS OF WORK
16 & 17 Year Olds
Must have completed 7
th
grade to work
while school is in session.
(EC 49112)
14 & 15 Year Olds
Must have completed 7
th
grade to work
while school is in session
(EC 49112)
12 & 13 Year Olds
Labor laws generally prohibit non-farm
employment of children younger than 14.
Special rules apply to agricultural work,
domestic work, and the entertainment
industry. (LC 1285–1312)
School In Session
4 hours per day on any schoolday
(EC 49112; 49116; LC 1391)
8 hours on any non-schoolday or on any
day preceding a non-schoolday.
(EC 49112; LC 1391)
48 hours per week (LC 1391)
WEE students & personal attendants
may work more than 4 hours on a
schoolday, but never more than 8.
(EC 49116; LC 1391, 1392)
3 hours per schoolday outside of school
hours (EC 49112, 49116; LC 1391)
8 hours on any non-schoolday
No more than 18 hours per week
(EC 49116; LC 1391)
WEE students may work during school
hours & up to 23 hours per week.
(EC 49116; LC 1391)
2 hours per schoolday and a maximum of
4 hours per week.
(EC 49112)
School Not In Session
8 hours per day (LC 1391, 1392)
48 hours per week (LC 1391)
8 hours per day (LC 1391, 1392)
40 hours per week (LC 1391)
8 hours per day (LC 1391, 1392)
40 hours per week (LC 1391)
Spread of Hours
5 a.m.–10 p.m. However, until 12:30
a.m. on any evening preceding a non-
schoolday (LC 1391)
WEE students, with permission, until
12:30 a.m. on any day (LC 1391.1)
Messengers: 6 a.m.–9 p.m.
7 a.m.–7 p.m., except that from June 1
through Labor Day, until 9 p.m.
(LC 1391)
7 a.m.–7 p.m., except that from
June 1 through Labor Day, until 9 p.m.
(LC 1391)
For more information about child labor laws, contact the U.S. Department of Labor at http://www.dol.gov/, and the State of
California Department of Industrial Relations, Division of Labor Standards Enforcement at http://www.dir.ca.gov/DLSE/dlse.html.
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STATEMENT OF INTENT TO EMPLOY A MINOR AND

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Completed 13 April 2021

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